The Thoracic and GI Surgery Services routinely handle referrals from the NCI Surgery Branch, Pediatric Oncology Branch, Endocrine Oncology Branch, Experimental Transplantation & Immunology Branch, as well as the National Heart, Lung, and Blood Institute, and other IC's. Thoracic Surgery volumes during the past 15 years have ranged from 150-175 cases annually, which have been covered by two thoracic surgeons. The vast majority of cases performed on the Thoracic Surgery Service are high index procedures in patients who have already had multiple surgeries and/or chemotherapeutic regimens, or are severely immunocompromised. These procedures include extrapleural pneumonectomies, radical pleurectomies, mediastinal exenterations with major vascular resections/reconstructions, chest wall resections, complex pulmonary resections and thoracoplasties for primary lung cancers, pulmonary metastases and multidrug resistant resistant mycobacterial or fungal infections, and esophagectomies. Sixty percent of all cases performed in the Thoracic Surgery Section, TGIB are consult cases; additionally, there are approximately 200 consults annually that do not result in operations in the short term, such as management of pneumothoraces, indeterminant pulmonary nodules, and second opinions, that nevertheless consume Thoracic Surgery resources. The GI Surgery Service performs 150-200 procedures annually; nearly 75% of these procedures are consult cases. These procedures range from lymph node biopsies, to port insertions/removals to small bowel resections for obstructions or perforations, to colectomies and abdominal-perineal resections for colorectal cancers in immunocompromised hosts, as well as hepatectomies for metastases or chronic granulomatous disease. Approximately 100-150 additional consult cases such as ruptured appendices, typhlitis or perforated ulcers in patients with severe neutropenia or CMV infections are managed non-surgically, but still require substantial time commitments. Since there are no cardiothoracic surgery fellows at the NCI, and because most of the physicians (PGY-3) entering the Surgical Oncology Program have not had any exposure to Thoracic Surgery, the majority of complex thoracic cases require two Thoracic Surgery attendings to assure patient safety. Similarly, because there are no senior-level general surgery residents, many of the complex general surgery resections require two attendings. Collectively, consult activities significantly distract Thoracic and GI Surgery personnel from their primary academic missions, and are performed without appropriate compensation or institutional/academic recognition; no other services at the NIH have these burdens. Presently, our ability to meet the increasing demand for thoracic and general surgical support at the NIH is limited by insufficient personnel in the Thoracic and GI Surgery Sections as well as significant OR staffing issues that NIH administrators have yet to properly address. The recent recruitment of an additional thoracic surgeon and one general surgical oncologist should enable more efficient surgical coverage of consult cases at the NIH.